Waiver Agreement - Section 32 WCL {C-32}pdf

WAIVER AGREEMENT - Section 32 WCL WCB CASE NO.(S) DATE(S) OF ACCIDENT CLAIMANT'S NAME (Please Print) CLAIMANT'S ADDRESS (Please Print) CARRIER CASE NO.(S) CARRIER CODE(S) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. CLAIMANT'S TELEPHONE (area code) EMPLOYER(S) (Please Print) CARRIER(S) (Please Print) TELEPHONE APPEARANCE REQUESTED (if hearing is needed) Contact number for telephone hearing (include area code): INTERPRETER NEEDED Type of Interpreter and Language Needed: MEDICAL REMAINS OPEN Other Parties of Interest (Please indicate if any additional parties are signatories): Additional Carrier(s) including DB carrier: Uninsured Employer's Fund Beneficiary in a Death claim Guardian in a Minor claim Special Funds Waiver Agreement Management Office (WAMO) Section 32 Waiver Agreement Conditions [Please indicate whether the waiver agreement settles all or some of the issues in the claim(s)]: Settles all issues and matters in the claim(s) identified by the WCB Claim number(s) above Settles some, but not all, issues and matters in the claim(s) identified by the WCB Claim number(s) above Liens (Please check the appropriate box and provide the page number where the issue is addressed): Child Support lien - see page(s): Disability Benefits lien - see pages(s): (Supporting document from jurisdiction required) Medical (Please check the appropriate box and provide the page number where the issue is addressed): Medical remains open - see page(s): CMS letter required - see page(s): WTCHP letter required - see page(s): Outstanding C-8.1 Part B objection(s) - see page(s): (Supporting document from CMS required) (Supporting document from WTCHP administrator required) Indemnity (Please check the appropriate box and provide the page number where the issue is addressed): Suspension of continuing payments - see page(s): Reinsurance Agreement - see page(s): Qualified Assignment - see page(s): (Documentation required) ; or if in CIS, Document ID#: Other: Pending appeal with the Board is withdrawn - see page(s): List any issues not mentioned in the above list that you would like the Board to consider and indicate the page(s) where the issue is addressed. THIS AGREEMENT IS PREPARED AND SUBMITTED PURSUANT TO SECTION 32 OF THE WORKERS' COMPENSATION LAW. BY SIGNING BELOW, EACH PARTY TO THE AGREEMENT AFFIRMS THAT (S)HE HAS READ AND UNDERSTANDS ITS PROVISIONS, AND UNDERSTANDS THAT THE AGREEMENT, IF APPROVED BY THE WORKERS' COMPENSATION BOARD, IS CONCLUSIVE, FINAL AND BINDING ON ALL THE PARTIES INVOLVED. IF THE AGREEMENT ALLOWS FOR FUTURE MEDICAL BENEFITS, THE BOARD MAY APPROVE THE AGREEMENT VIA DESK REVIEW. OTHERWISE ALL SIGNATORIES MUST CONSENT TO DESK REVIEW. THE UNDERSIGNED HEREBY CONSENT OF THEIR OWN FREE WILL TO BE SUBJECT TO THE ABOVE PROVISIONS AND ACKNOWLEDGE RECEIPT OF A COPY OF THIS AGREEMENT. CLAIMANT - PLEASE PRINT CLAIMANT SIGNATURE CONSENT FOR DESK REVIEW DATE CARRIER OR SELF-INSURED EMPLOYER - PLEASE PRINT CARRIER OR SELF-INSURED EMPLOYER SIGNATURE CONSENT FOR DESK REVIEW DATE CLAIMANT ATTORNEY, SPECIAL FUNDS OR OTHER - PLEASE PRINT CLAIMANT ATTORNEY, SPECIAL FUNDS OR OTHER SIGNATURE CONSENT FOR DESK REVIEW DATE C-32 (2-16) American LegalNet, Inc. www.FormsWorkFlow.com SEE IMPORTANT INFORMATION ON THE REVERSE Instructions for Completing the Section 32 Waiver Agreement In order to expedite the resolution processing of the Section 32 Waiver Agreement, the parties are requested to follow these instructions. Failure to follow these instructions and to provide the necessary accompanying documents may result in the resolution of the Section 32 Agreement being delayed. The statute and regulation pertaining to Section 32 Waiver Agreements (WCL§ 32 and 12 NYCRR 300.36) is available at www.wcb.ny.gov. 1. Form: Submit a legible Form C-32. The terms of the agreement must be in a single separate attachment. If it becomes necessary to modify the agreement, please submit a new amended agreement incorporating the modifications, rather than an addendum. Any Claim included in a Section 32 Waiver Agreement must be assembled and assigned a Case Number by the Board. A copy of the Section 32 Waiver Agreement must be submitted for each claim included in the agreement. 2. Page Numbers: Number the pages of the document as follows: Page 1 of 4, Page 2 of 4, etc. 3. Signatories: Have all parties in interest, including the guardian for minor claimants if any, sign and date Form C-32 and the final page of the Section 32 Waiver Agreement prior to submission. Special Funds or the Waiver Agreement Management Office (WAMO) must also be a signatory and date Form C-32 if WCL §§ 14(6) or 15(8) have been found applicable to the case(s). Special Funds must sign and date Form C-32 if 25-a has been found applicable to the case(s). If a disability benefits lien is addressed in the Section 32 Waiver Agreement, then the Disability Benefits Carrier must sign. 4. Necessary Provisions: Address the resolution of these issue(s) if any have been raised or are still pending before the Board at the time of the agreement: l l l l disputed medical bills (Form C-8.1B) tentative rates periods held in abeyance when continuing payments will stop l l l l wage expectancy of a minor outstanding requests for attorney's fees (OC-400.1's) responsibility for future medical treatment disability benefits lien 5. Language to Avoid: Do not include references to: l l l l l a claim(s) being "disallowed" or "disallowed" by stipulation an unassembled claim(s) that has (have) not been assigned a Case Number by the Board a waiver of the ten day withdrawal period identifiable confidential information pertaining to an individual not a party to the agreement when the agreement becomes binding The Board will not approve any agreement which provides that a claim is "disallowed" by stipulation of the parties because such language implies a finding by the Board, which is not the case. If a claim has not yet been established, the agreement may indicate that the claim is being "withdrawn" by the claimant. 6. Pending Appeals: If there is a pending Appeal for a case included in a Section 32 Waiver Agreement, the agreement must indicate that the appeal is withdrawn or resolved. The Board will not approve Section 32 Waiver Agreements for claims that have an unresolved pending Appeal. 7. Annuity: If the agreement references future payments based upon the purchase of an annuity contract, provide a summary specifying all of the following: that th